Outcomes among Athletes with Arrhythmias and Electrocardiographic Abnormalities: Implications for ECG Interpretation

Exercise and Athletic Activity in Atrial Fibrillation

Moderate-intensity exercise improves cardiovascular outcomes. However, mounting clinical evidence demonstrates that long-term, high-intensity endurance training predisposes male and veteran athletes to an increased risk of atrial fibrillation (AF), a risk that is not observed across both genders. Although increased mortality associated with AF in the general population is not shared by athletes, clinically significant morbidities exist (eg, reduced exercise capacity, athletic performance, and quality of life). Additional research is needed to fill current gaps in knowledge pertaining to the natural history, pathophysiologic mechanisms, and management strategies of AF in the athlete.

Association of electrocardiographic left and right ventricular hypertrophy with physical fitness of military males: The CHIEF study

AIM

To investigate the association of electrocardiographic (ECG) left and/or right ventricular hypertrophy (LVH and RVH) with physical fitness of military males.

METHODS

We used a military cohort of 2587 males, who were on average 29.1 years of age, from the cardiorespiratory fitness and hospitalization events in armed forces (CHIEF) study in Taiwan for the analysis. Isolated ECG-LVH (n = 779) was diagnosed by either the Sokolow-Lyon or Cornell voltage criteria. Isolated ECG-RVH (n = 234) was defined by either the Sokolow-Lyon or Myers et al. voltage criteria. Combined ECG-LVH/RVH (n = 140) was defined as those who met the voltage criteria for both LVH and RVH. The other ECGs were defined as unaffected (n = 1434). Physical fitness was evaluated by the upper and lower 16% exercise performance (beyond 1-standard deviation) in 3000-meter run, 2-minute sit-ups, and 2-minute push-ups. All procedures were standardized and monitored by unified computerized scoring systems. A multiple logistic regression was used to determine the relationship.

RESULTS

Compared with unaffected participants, those with an isolated ECG-LVH were tended to have a better 3000-meter run performance (odds ratio (OR) and 95% confidence intervals: 1.22 [0.99-1.50], p-value = 0.064) after adjusting for age, service specialty, body mass index, mean blood pressure, smoking status, alcohol intake, hemoglobin level, and exercise frequency. By contrast, those with an isolated ECG-RVH were tended to have a worse 2-minute sit-up performance (OR: 1.46 [0.99-2.16], p-value = 0.054).

CONCLUSION

Military males with ECG-LVH and/or ECG-RVH compared to unaffected participants may have diverse exercise performances. However, these observations narrowly failed to reach statistical significance.

Young athletes with ventricular premature beats: Continuing or not intense training and competition?

Isolated ventricular premature beats (VPBs) are commonly found during pre-participation screening in athletes. Currently, the debate about the role of detraining in reducing the number of VPBs is still open. This study evaluated the arrhythmic risk in a population of young competitive athletes who showed VPBs during eligibility evaluation and that did not undergo detraining but continued practicing competitive sports. 3746 consecutive subjects underwent pre-participation screening. Athletes who showed VPBs were selected and underwent second level evaluation (Echocardiogram, 24 hour Holter ECG and Exercise test). Athletes were re-evaluated after a follow-up period (6-48 months) while they continued practicing competitive sports. 5.3% of the whole population showed ventricular arrhythmias. 73% of the subjects showed isolated VPBs. 88% of the subjects showed monomorphic VPBs, and 12% of athletes showed polymorphic VPBs. At echocardiogram, there was not any pathology which contraindicated competitive sport activity. At 24 hour Holter ECG recording, mean number of daily VPBs was 1592±3217 (range 0-16678). At holter ECG follow-up (16±12 months), the median number of VPBs decreased from 93 (IQR 20-3065) to a new value of 72 (IQR 2-1299). Continuing competitive sport in subjects with ventricular arrhythmias even though frequent but with a low grade of complexity and without structural cardiomyopathy does not increase sudden death risk.

Muerte Súbita Cardíaca en Atletas. Conocimiento e importancia del tamizaje

Introducción: La muerte súbita de atletas jóvenes competitivos continúa causando impacto no solamente entre el público y la comunidad atleta, sino también entre la médica. Estas muertes han sido reportadas con un aumento en su frecuencia tanto en los Estados Unidos, como en los países latinos y Europeos. Estos eventos han causado gran impacto, han dado lugar a una mayor discusión e investigación entre las asociaciones médicas para su prevención. En Guatemala aun no existe un tamizaje a seguir. Objetivos. El objetivo del estudio fue determinar que tanto existe conocimiento del tema entre los deportistas de alto nivel, y que tanto conocen sobre su propio riesgo de padecer del evento. Métodos: Estudio de tipo descriptivo, con técnicas cualitativas y cuantitativas de tipo transversal de 217 atletas de la CDAG. Resultados: Existe evidencia estadísticamente significativa que más del 50% de los atletas no conocen sobre su riesgo personal (con intervalo de 95% de confianza), y que más del 50% tiene un nivel de conocimiento adecuado respecto al tema. Conclusiones: Entre los atletas estudiados hay individuos con factores de riesgo importantes de evento súbito cardiovascular y sin embargo realizan ejercicio extenuante sin tener una evaluación de rutina. Es necesario fortalecer la evaluación médica en los atletas competitivos guatemaltecos y crear más conciencia del tema. 

Rare medical manifestations of severe restricting and purging: "Zebras," missed diagnoses, and best practices

OBJECTIVE

Medical problems that arise due to severe restricting and/or purging may be misdiagnosed or suboptimally treated, from outpatient clinics to top medical hospitals. A symptom may be presumed to be a psychological manifestation of the eating disorder and inappropriately dismissed for further medical evaluation. Alternatively, a detailed medical workup may be performed, overlooking a classic relationship between starvation and a physical finding, which delays referral to eating disorder care. This review article focuses on rare medical issues (also called "zebras" in medical training), diagnoses that may be missed in patients with eating disorders, and best practices for management, organized by organ system.

METHOD

A PubMed search was performed, using search terms "eating disorder," "anorexia nervosa," and "bulimia nervosa" in combination with different words for each organ system and known medical manifestations of severe eating disorders, with high quality and relevant studies from the past 20 years cited.

DISCUSSION

Adults with eating disorders may present with extreme organ dysfunction and atypical signs and symptoms of typical medical problems. Timely diagnosis, risk awareness, appropriate treatment, and avoidance of harm are all vital. With judicious management and nutritional rehabilitation, most of these complications will significantly improve or resolve. ©

Benign and pathological electrocardiographic changes in athletes

Sudden cardiac death is the leading cause of death in athletes during sport. It is a tragic event that generates significant media attention and discussion throughout society as to whether everything possible had been done to prevent it. Regular physical exercise causes cardiac remodeling at both the mechanical and electrical level, known as athlete's heart, resulting in an electrocardiogram (ECG) considered abnormal compared with the ECGs of the general population. Some of these electrocardiographic changes are considered normal or physiological in athletes, while others suggest underlying cardiac disease with the potential to cause sudden cardiac death. There is thus an urgent need to define the electrocardiographic patterns that allow or prohibit participation in sports, and to differentiate them in terms of gender, ethnicity and age. The purpose of this review is to present the latest data on the electrocardiographic changes considered benign or pathological that are typically found in athletes and to critically analyze the most recent criteria for classifying ECGs in this population (the Seattle criteria), comparing them with previous guidelines and with the latest studies on the subject. This article also examines the question of including ECGs in pre-participation screening programs, the US and European approaches to the subject, and the most up-to-date data on the sensitivity, specificity and cost-effectiveness of the ECG in athletes.